Nonlinear Relations of Blood Pressure to Cognitive Function

The Baltimore Longitudinal Study of Aging

Shari R. Waldstein, Paul P. Giggey, Julian F. Thayer, Alan B. Zonderman

AbstractThis investigation examined cross-sectional and longitudinal relations, both linear and nonlinear, of blood
pressure (BP) and its interaction with demographic and lifestyle variables to a broad spectrum of cognitive functions.
Eight hundred forty-seven participants (503 men and 344 women) from the Baltimore Longitudinal Study of Aging
completed tests of verbal and nonverbal memory, attention, perceptuo-motor speed, executive functions, and
confrontation naming, and clinical assessment of BP on 1 to 7 occasions over 11 years. Mixed-effects regression models,
adjusted for age, education, gender, alcohol consumption, smoking status, depression scores, and use of antihypertensive
medications, revealed nonlinear relations of systolic BP with longitudinal change on tests of nonverbal memory and
confrontation naming; cognitive decline was apparent among older (80 years) individuals with higher systolic BP.
Cross-sectional findings, across testing sessions, indicated moderated U- and J-shaped relations between BP and
cognitive function. Both high and low diastolic BP were associated with poorer performance on tests of executive
function and confrontation naming among less-educated persons; with tests of perceptuo-motor speed and confrontation
naming among nonmedicated (antihypertensives) individuals; and with executive function among older individuals.
Cross-sectional linear relations included higher systolic BP and poorer nonverbal memory in nondrinkers, and higher
diastolic BP and poorer working memory among less-educated individuals. Results indicate that cross-sectional and
longitudinal relations of BP to cognitive function are predominantly nonlinear and moderated by age, education, and
antihypertensive medications. Careful monitoring and treatment of both high and low BP levels may be critical to the
preservation of cognitive function. (Hypertension. 2005;45:374-379.)
Key Words: blood pressure hypertension cognitive function neuropsychology

H ypertension is a major risk factor for stroke, vascular

dementia, and possibly Alzheimers disease.1,2 Even
among stroke-free and dementia-free persons, hypertension or
higher blood pressure (BP) levels have been related to lowered
levels of cognitive function in numerous cross-sectional and
longitudinal investigations.35 However, not only high BP but
also low BP levels have negative effects on cognitive function.
Low BP has been related to risk for Alzheimers disease and
diminished cognitive function.6 Furthermore, U-shaped relations
between BP and cognitive function have been noted such that
individuals with high or low BP perform more poorly on
cognitive tests and/or display more pronounced cognitive de-
cline than persons with mid-range BP.79 With one exception,5
these studies are limited by the assessment of BP, cognitive
function, or both on a single occasion.
The purpose of the present investigation was to examine
both cross-sectional and longitudinal relations of concur-
rently measured BP and cognitive function across 1 to 7
testing sessions in a single stroke and dementia-free sample
while evaluating potential nonlinear associations, effect mod-
ifiers, and a broad spectrum of cognitive functions. To our
knowledge, only 1 previous investigation has assessed con-
currently measured BP and cognitive function on 2 testing
occasions in a small sample (n140).5 Although several
previous studies have examined nonlinear relations of BP to
cognition,79 few domains of cognitive function were mea-
sured (ie, global mental status, verbal memory, perceptuo-
motor speed), there was limited assessment of effect modifi-
cation, and persons with stroke or dementia were included
(which may lead to overestimation of BP cognition rela-
tions). Here, we examined measures of verbal and nonverbal
memory, attention, perceptuo-motor speed, executive func-
tions, and confrontation naming, and potential interactions of
BP with several demographic and lifestyle variables.
Methods
Participants
Participants from the Baltimore Longitudinal Study of Aging
(BLSA), a prospective study of community-dwelling volunteers
initiated by the National Institute on Aging in 1958, return to the
Gerontology Research Center in Baltimore every 2 years for
medical, psychological, and cognitive testing.10 Beginning in 1986,
participants 60 years and older were administered a more extensive

Received August 30, 2004; first decision September 22, 2004; revision accepted January 11, 2005.
From Department of Psychology (S.R.W., P.P.G.), University of Maryland, Baltimore County, Baltimore, Md; and Laboratory of Personality and
Cognition (S.R.W., P.P.G., J.F.T., A.B.Z.), Gerontology Research Center, National Institute on Aging, Baltimore, Md.
Correspondence to Shari R. Waldstein, PhD, Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Cir, Baltimore, MD
21250. E-mail waldstei@umbc.edu
2005 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org DOI: 10.1161/01.HYP.0000156744.44218.74

374
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 Waldstein et al Blood Pressure and Cognitive Function 375

TABLE 1. Characteristics of Study Sample at First BLSA learning slope, short and long free recall), and the Benton Visual
Visit (n847) Retention Test (BVRT) (n796) evaluated nonverbal memory. Trail
Making Test Parts A and B (n847) assessed attention, perceptuo-
Variable Mean SD Minimum Maximum motor speed, visuomotor scanning, and mental flexibility (an executive
Age, y 70.6 (8.5) 39 96 function). Letter Fluency (n847) and Category Fluency (n847)
examined phonetic and semantic association fluency, respectively, and
Education, y 16.6 (2.7) 4 24
executive function. The Boston Naming Test (n847) assessed con-
Gender, % male 59 frontation naming (ie, word finding).
Race, % white 84.2
Alcohol use* 0 (2) 0 11
Blood Pressure
At each study visit, BP was measured in the morning by trained
Ever smoker, % 59 nursing staff at least 90 minutes after a light breakfast. After a
Antihypertensive 33.4 5-minute rest period, a mercury sphygmomanometer with an
medication, % appropriate-sized occluding cuff was used to measure BP once from
CES-D 6.5 (6.3) 0 45 each arm while patients sat in an upright position. Systolic BP and
diastolic BP were determined by Kortokoff phase I and phase V,
SBP, mm Hg 138.7 (20.0) 90 220 respectively. The 2 measurements were averaged for data analysis.
DBP, mm Hg 82.0 (10.9) 50 115
*1 unit of alcohol use corresponds to 1.4 drinks per week. Data presented Covariates
for alcohol use are the median and interquartile range Age and education were assessed in years. Alcohol use was quanti-
CES-D indicates Center for Epidemiological Studies Depression Scale; DBP, fied categorically according to types and numbers of drinks (one
diastolic blood pressure; SBP, systolic blood pressure. drink12 ounces beer, 4 to 5 ounces of wine, or 2 ounces of spirits)
consumed per week. Categorical ratings obtained at each visit were
added to yield a single score. Smoking status was defined as
neuropsychological test battery. The present analyses were limited to never/ever. Use of antihypertensive medications was collapsed
visits occurring on or after January 1, 1986, resulting in 928 into a single yes/no category. Depressive symptomatology was
participants (ages 39 to 96) available for potential inclusion. We examined using the Center for Epidemiological Studies Depression
excluded persons with dementia (n34;11), cerebrovascular diseases Scale (CES-D).13
including stroke (n55), and renal failure (n1) across all assess-
ment visits. Eight hundred forty-seven participants (503 men and 344
women) met study criteria. Baseline sample characteristics are Data Analyses
presented in Table 1. The total number of participants per visit is Mixed-effects regression analyses were conducted to examine cross-
listed in Table 2. Because the BLSA uses continuous enrollment sectional (collapsed across all testing sessions) and longitudinal
procedures, participants have different numbers of visits, in part, relations of BP to cognitive function. Mixed-effects models are the
because of differential start times in the project. Follow times are preferred method of analyzing data with different numbers of
also variable. Participants had an average of 2.7 (SD1.5) visits, and repeated outcome measurements that are obtained at nonuniform
the average time between visits was 2.32 (SD0.8) years. Number intervals.14,15 These analyses model change over time by computing
of follow-up visits (mean, SD, range) by 10-year increments in age rate of change for each participant based on all data for that
are as follows: 50 to 60 years (2.80, 1.79, 1 to 6); 60 to 70 years individual. The model computes rate of change for the entire group
(2.82, 1.44, 1 to 6); 70 to 80 years (2.93, 1.54, 1 to 7); 80 to 90 years and then computes each individuals deviation from the group rate.
(2.18, 1.31, 1 to 6); and 90 to 100 years (1.33, 0.71, 1 to 3). Over the Mixed-effects models evaluate the unique effects of individual
course of the investigation, 11 participants died and 7 formally predictors adjusted for all other predictors in the model, includes
withdrew from the investigation; therefore, rate of attrition was 2%. both fixed and random effects, accounts for the correlation among
Institutional Review Board approval was obtained from the Johns repeated measurements on the same participant, and is unaffected by
Hopkins Bayview Medical Center for the investigation and the randomly missing data. In the present instance, it permits analysis of
University of Maryland, Baltimore County for the current data the rate of change in cognitive performance as a function of rate of
analyses. All participants provided written informed consent. change in BP (and all relevant covariates).
To maximize the unique information provided by each neuropsycho-
Neuropsychological Tests logical test, separate models were examined for each test as a dependent
At each study visit, standard neuropsychological tests were administered measure. Separate models were constructed for systolic BP and for
by extensively trained psychometricians.12 The sample sizes that follow diastolic BP. Both linear and quadratic (squared) effects were included
each test indicate respective reductions in sample size because of in each model. Baseline age, years of education, alcohol consumption,
test-specific missing data. The Digits Forward and Backward portions of depression scores, and time interval between assessments were treated
the Wechsler Adult Intelligence ScaleRevised (n733) assessed atten- as continuous covariates, and gender, antihypertensive medications, and
tion and working memory. The California Verbal Learning Test smoking status were treated as categorical covariates. Baseline age
(n689) measured verbal learning and memory (ie, List A total, indexes cross-sectional age differences, whereas time interval (ie, years
since baseline testing for each administration of the dependent measure)
indexes longitudinal age change.
TABLE 2. Sample Size by Number of Repeat Administrations All main effects and 2-way interactions were entered into each
No. of Repeat model in addition to the 3-way interactions of baseline age, linear
Administrations No. (% of Sample) BP, and time interval, and baseline age, quadratic BP, and time
interval. A backward elimination procedure was used in which
2 595 (70.2) nonsignificant interaction terms (P0.05) were eliminated from
3 438 (51.7) each model until a final solution was reached. Significant effects of
BP on longitudinal rate of cognitive change are indicated by
4 296 (34.9)
significant interactions of BP and time interval (or the 3-way
5 106 (12.5) interaction of age, BP, and time interval). Cross-sectional relations of
6 26 (3.1) BP and cognition (mean cognitive test scores collapsed across all
testing sessions) are revealed by BP main effects or interactions of
7 3 (0.004)
BP with demographic or lifestyle covariates.

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376 Hypertension March 2005

TABLE 3. Summary of Significant Systolic Blood Pressure Effects From

Mixed-Effects Regression Analyses
Neuropsychological Test* Significant SBP Effects Coefficient F P
Benton Visual Retention Test Interval*SBP linear 0.03381 7.33 0.007
Alcohol*SBP linear 0.00412 4.32 0.04
Age0*Interval*SBP linear 0.00049 8.01 0.005
Interval*SBP quadratic 0.04332 7.79 0.005
Age0*Interval*SBP quadratic 0.00062 7.84 0.005
Boston Naming Test SBP linear 0.03284 5.74 0.02
Age0*SBP linear 0.00046 5.95 0.02
Interval*SBP linear 0.01003 9.30 0.002
Age0*Interval*SBP linear 0.00015 9.89 0.002
SBP quadratic 0.04416 7.62 0.006
Age0*SBP quadratic 0.00064 8.25 0.004
Interval*SBP quadratic 0.00837 4.00 0.05
Age0*Interval*SBP quadratic 0.00012 4.44 0.04
*Separate regression models were computed for each neuropsychological test. Each model
contained all relevant main effects and interaction terms as detailed in text. However, for
space-saving purposes, we only report significant findings for each model in this table. Complete data
for each model are available from the authors.
Regression coefficients, although indicative of effect sizes may be misleading because of
correlations among main effects and interactions.

Statistical analyses were conducted using SAS versions 6.12 and
8.02 (Cary, NC). Graphs were created to visualize the significant
relations using the prototypical values of the predictors.14 In the
reporting of results in text, significant interaction effects were
presumed to qualify main effects and significant effects of quadratic
BP were presumed to qualify those that involved linear BP.
Results
Significant main and interactive effects of systolic and
diastolic BP with respect to the cognitive outcomes are
listed in Tables 3 and 4, respectively. Longitudinal find-
ings were as follows. First, a significant 3-way interaction
of baseline age, time interval, and quadratic systolic BP
was noted for the BVRT and the Boston Naming Test.
Graphic depiction of predicted parameters associated with
these interactions (Figure) indicates, for the BVRT, that
among younger individuals (age 60 at baseline), those with
higher systolic BP made more errors on the BVRT than
those with normal BP but improved over time (ie, practice
effects). In contrast, among older individuals (age 80 at
baseline), those with higher systolic BP declined in BVRT
performance over time. On the Boston Naming Test,
younger individuals (age 60 at baseline) with higher
systolic BP performed more poorly than those with lower
systolic BP across testing sessions. For older individuals
(age 80 at baseline), those with higher systolic BP declined
in performance over time.
Next, several cross-sectional findings (across all testing
sessions) were noted. Significant linear relations of BP to
cognitive function were almost always qualified by nonlinear
(ie, quadratic) effects (please see http://hyper.ahajournals.org
for Figure I depicting all quadratic associations). Specifically,
significant nonlinear relations of diastolic BP and education
were found for the Boston Naming Test and Trail Making B. For
Boston Naming, individuals with lower levels of education and
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either high or low BP performed more poorly than those with
mid-range BP (a U-shaped relation). For Trail Making B, a
J-shaped relation revealed that among less educated persons,
those with high or low BP performed more poorly than those
with mid-range BP, but particularly among those with high BP.
On both tests, individuals with higher levels of education
performed similarly irrespective of BP level.
Significant interactive effects of quadratic diastolic BP and
use of antihypertensive medication were noted for the Boston
Naming Test and Trail Making A. For Boston Naming,
individuals who were not medicated displayed poorer perfor-
mance at both high and low BP levels (as compared with
mid-range); medicated individuals performed similarly at all
levels of BP. For Trail Making A, a J-shaped relation was
noted such that among nonmedicated persons, those with
higher BP displayed poorer performance than those with
mid-range BP; those with lower BP also displayed poorer
performance than those with mid-range BP, although to a
lesser extent than persons with high BP.
Significant interactive effects of quadratic diastolic BP and
baseline age were identified for Letter Fluency. At younger ages,
higher diastolic BP levels conferred a slight performance advan-
tage. At older ages, those with high and low diastolic BP
performed more poorly than those with mid-range BP. The
effect was more pronounced for those with higher BP.
Finally, results revealed 2 significant, cross-sectional, and
linear relations of BP to cognitive function that were not
qualified by quadratic effects (Figure II). An interaction of
systolic BP and alcohol consumption was found for the
BVRT. Higher systolic BP was associated with more BVRT
errors among nondrinkers than individuals who reported
drinking alcohol. An interaction of diastolic BP and education
for Digits Backward revealed that less-educated individuals
with higher BP performed worse on this test than their more
educated counterparts.
 Waldstein et al Blood Pressure and Cognitive Function 377

TABLE 4. Summary of Significant Diastolic Blood Pressure Effects From

Mixed-Effects Regression Analyses
Neuropsychological Test* Significant DBP Effects Coefficient F P
Boston Naming Test DBP linear 0.37700 11.12 0.0009
Education*DBP linear 0.01732 7.01 0.008
Medication*DBP linear 0.08183 6.37 0.01
DBP quadratic 0.23670 11.71 0.0007
Education*DBP quadratic 0.01098 7.55 0.006
Medication*DBP quadratic 0.05097 6.73 0.01
Digits Backward DBP linear 0.02766 13.81 0.0002
Education*DBP linear 0.00173 26.97 0.0001
Letter Fluency DBP linear 1.0793 4.95 0.03
Age0*DBP linear 0.01500 4.81 0.03
DBP quadratic 0.6992 5.53 0.02
Age0*DBP quadratic 0.00967 5.3 0.02
Trail Making A DBP linear 0.9491 7.67 0.006
Medication*DBP linear 1.1140 4.65 0.03
DBP quadratic 0.6046 8.23 0.004
Medication*DBP quadratic 0.6998 5.00 0.03
Trail Making B DBP linear 18.3200 11.86 0.0006
Education*DBP linear 0.9549 9.48 0.002
DBP quadratic 11.602 12.82 0.0004
Education*DBP quadratic 0.6064 10.33 0.001
*Separate regression models were computed for each neuropsychological test. Each model
contained all relevant main effects and interaction terms as detailed in text. However, for
space-saving purposes, we only report significant findings for each model in this table. Complete data
for each model are available from the authors.
Regression coefficients, although indicative of effect sizes, may be misleading because of
correlations among main effects and interactions.

Discussion BP showed longitudinal decline on tests of nonverbal mem-

This study examined both cross-sectional and longitudinal
relations of concurrently measured BP and cognitive function
across 1 to 7 testing sessions in a moderately large stroke-free
and dementia-free sample while evaluating potential nonlin-
ear associations, multiple relevant effect modifiers, and a
fairly extensive range of neuropsychological tests. In almost
all instances, significant linear relations of BP to cognitive
function were qualified by nonlinear associations. This is, to
our knowledge, the first report of age-moderated, nonlinear
relations of systolic BP to longitudinal change in cognitive
performance, in addition to cross-sectional (across testing
sessions), nonlinear relations of BP to cognitive function that
are moderated by age, education, and antihypertensive med-
ication. Measurement of concurrent BP and cognitive func-
tion on 2 testing occasions greatly strengthens measure-
ment reliability and ability to track longitudinal covariation in
these 2 variables.
With respect to longitudinal change in cognitive function,
we found that among individuals age 60 years at baseline,
those with higher systolic BP performed more poorly than
those with lower systolic BP across all sessions on a test of
confrontation naming. This cohort also performed more
poorly on a test of nonverbal memory but showed improve-
ment over time (likely reflecting practice effects). In contrast,
among persons age 80 at baseline, those with higher systolic
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ory and confrontation naming. Thus, elderly persons may be
most vulnerable to the cognitive consequences of higher
systolic BP over time. Interesting, these same tests of non-
verbal memory and confrontation naming have shown pre-
dictive usefulness with respect to later development of
dementia in the larger BLSA sample and other studies.16,17
Previous longitudinal investigations have not noted interac-
tive relations of age and BP to cognitive decline in cohorts of
similar (although not identical) age range.9,18 However, non-
linear effects were not always examined, there were fewer
follow-up visits, and dissimilar cognitive tests were used.
Next, the present findings revealed a series of significant
cross-sectional, U-shaped, and J-shaped relations of diastolic
BP to cognitive function that were moderated by age, educa-
tion, and use of antihypertensive medications. Previous work
has shown high BP to be moderated by these variables.3,19
However, to our knowledge, this is the first report that
elderly, less-educated, and nonmedicated (with antihyperten-
sives) persons are most vulnerable to negative effects of both
high and low BP on select tests of executive function,
confrontation naming, and perceptuo-motor speed; on aver-
age, these subgroups of individuals displayed lower levels of
cognitive function across all testing sessions. Even in the
absence of significant decline, such persistently lower levels
of cognitive function among these subgroups may have
378 Hypertension March 2005

Longitudinal rate of change in cognitive performance as a function of age and systolic BP for the Benton Visual Retention Test (panel 1)
and the Boston Naming Test (panel 2). Color-coding depicts relatively higher (red) and lower (blue) test scores.

implications for quality of life and daily functioning, and exacerbated in the presence of higher BP. In addition, and
therefore may be clinically meaningful. similar to previous work, we noted that higher diastolic BP
Finally, effect modification was also noted with respect to was associated with poorer performance on a test of working
linear BP. Higher levels of systolic BP were associated with memory among less educated individuals
poorer performance on a test of nonverbal memory among Younger age, higher levels of education, use of antihyper-
nondrinkers. Less alcohol consumption has previously been tensive medications, and some alcohol use may protect
associated with poorer cognitive function,20 a risk that may be against the neurobiological consequences of high BP,3 and
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 Waldstein et al
thereby cognitive performance. Relevant mechanisms include
enhanced white matter disease, small silent infarctions, brain
atrophy, and atherosclerosis in the large cerebral and cervicoce-
rebral arteries, and reduced cerebral blood flow or metabolism.
Lower BP may negatively affect cognitive function by similar
means via insufficient cerebral perfusion and associated neuro-
pathology. Individuals with lower BP may also have comorbid
cardiovascular conditions, perhaps involving left ventricular
dysfunction, which may also negatively affect cognitive func-
tion.21 It is possible that over time, the cognitive and neurobio-
logical correlates of hypotension and hypertension may progress
to mild cognitive impairment and/or dementia. Cerebral hypo-
perfusion may be particularly relevant to the future development
of vascular dementia and Alzheimers disease.22
Limitations to this investigation include the sample of conve-
nience, which was generally highly educated and predominantly
white, thus limiting the studys generalizability. Next, because
the sample was followed frequently for medical comorbidities,
hypertensive participants were most often medicated. Although
critical for ethical reasons, it is apparent from previous investi-
gations that BP effects on cognition are more pronounced among
untreated individuals.35,19 It is unclear why systolic and diastol-
ic BP displayed differential relations to cognitive outcomes. It is
possible that this, in part, reflects the known heterogeneity of
hypertension and differential underlying factors (eg, genetic,
hormonal, hemodynamic) that contribute to systolic versus
diastolic BP elevation. Finally, the rate of attrition in the present
study is unusually low. This may be attributable to that fact that
study participants are contacted regularly and retain close ties
with study staff. In addition, participants receive extensive
medical evaluation and treatment as part of the study that may
affect overall mortality rates.
To conclude, the present findings largely indicate U-shaped
and J-shaped relations of BP to both cross-sectional and longi-
tudinal cognitive performance that are moderated by age, edu-
cation, or use of antihypertensive medications. Minimal linear
relations of BP to cognition were also noted as a function of
education and alcohol use. These findings indicate that studies of
BP and cognitive function should routinely examine nonlinear
trends. These results further suggest that careful monitoring and
treatment of both high and low BP levels, and perhaps associated
maintenance of adequate cerebral perfusion, may be critical to
the preservation of cognitive function.
Perspectives
Results of this study indicate that examination of effect
modifiers is critical to understanding the relation of BP to
cognitive function and highlights the need to further under-
stand factors that increase individuals vulnerability to the
cognitive consequences of high or low BP. Furthermore,
persons who display cognitive dysfunction or decline in
association with hypertension or hypotension should be
followed-up for future incidence of mild cognitive impair-
ment and dementia. Increased awareness is needed that the
brain is an early target organ of both high and low BP before
stroke or dementia. Future research should address whether
the biological underpinnings of BP cognition relations differ
among subgroups of individuals and further determine
whether the normalization of BP level by antihypertensive
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Blood Pressure and Cognitive Function 379
treatment can prevent cognitive decline and dementia.23 In
that regard, results of further clinical trials will be critical.
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Figure I: Interaction of nonlinear (quadratic) diastolic BP and education for the Boston

Naming Test and Trail Making B; quadratic diastolic BP and antihypertensive medication

use for the Boston Naming Test and Trail Making A; quadratic diastolic BP and age for

Letter Fluency. Higher scores indicate worse performance on Trail Making A and B. All

results are cross-sectional (collapsed across all testing sessions).

Figure II: Interaction of linear systolic BP and alcohol consumption for the Benton Visual

Retention Test, and linear diastolic BP and education for Digits Backward. Results are

cross-sectional (collapsed across all testing sessions).

 15.00 160
12 year education 12 years education
16 years education 16 years education
14.75 150

14.50 140
Predicted Boston Naming score

Predicted Trails B (sec) score

14.25 130

14.00 120

13.75 110

13.50 100

13.25 90

13.00 80
60 65 70 75 80 85 90 95 100 105 110 60 65 70 75 80 85 90 95 100 105 110
Diastolic blood pressure Diastolic blood pressure

15.00 48
Medication Medication
No medication No medication
14.75 47

14.50 46
Predicted Boston Naming score

Predicted Trails A (sec) score

14.25 45

14.00 44

13.75 43

13.50 42

13.25 41

13.00 40
60 65 70 75 80 85 90 95 100 105 110 60 65 70 75 80 85 90 95 100 105 110
Diastolic blood pressure Diastolic blood pressure

18
60 yo
70 yo
80 yo
17
Predicted Letter Fluency score

16

15

14

13

12
60 65 70 75 80 85 90 95 100 105 110
Systolic blood pressure
 20 8.0
No drinking 12 years education
Moderate drinking 16 years education
18
Predicted Benton Visual Retention Test errors

7.5
16

14 Predicted Digits Backward score

7.0
12

10 6.5

8
6.0
6

4
5.5
2

0 5.0
110 120 130 140 150 160 170 180 190 200 210 60 65 70 75 80 85 90 95 100
Systolic blood pressure Diastolic blood pressure
Nonlinear Relations of Blood Pressure to Cognitive Function: The Baltimore Longitudinal
Study of Aging
Shari R. Waldstein, Paul P. Giggey, Julian F. Thayer and Alan B. Zonderman

Hypertension. 2005;45:374-379; originally published online February 7, 2005;

doi: 10.1161/01.HYP.0000156744.44218.74
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